PPD Literature Review This work in writing seeks to answer the question of what the relationship is between domestic violence, sexual abuse, and women with depression during the postpartum period. Toward this end, this work will involve the conduction of an extensive review of literature in this area of study. The literature reviewed will be that located in scholarly publications and journals and other publications of a professional or academic and peer-reviewed nature.

Problem Formulation

The work of Jana L. Jasinski (2004) entitled "Pregnancy and Domestic Violence" states that estimates of violence against women indicate that approximately two million women are "physically assaulted annually and more than 50 million are assaulted in their lifetime. (p.48) Jasinski notes that estimations of the prevalence of violence during pregnancy experiences variations "due to differences in research designs, measures used, and populations sampled." (2004, p.49) In addition, a discrepancy exists as hospital and clinic-based studies report that there is an increased risk for violence during pregnancy however; national studies do not report the same findings. (Jasinski, 2004, paraphrased) The results of violence during pregnancy are inclusive of "later entry into prenatal care, low birth weight babies, premature labor, fetal trauma, unhealthy maternal behaviors, and health issues for the mother." (Jasinski, 2004, p.49) Finally, Jasinski reports that those most likely to screen for violence are health care providers who have received training however, the problem appears to be that very few providers are on the receiving end of such training in coordination with their medication education. (Jasinski, 2004, paraphrased)

Literature Review

The work of Palmer (2010) entitled "A Qualitative Study of Existential Issues in Postpartum Depression: An Unspoken Truth" relates that while "…a serious medical and psychological disorder, postpartum depression (PPD) has only in the last decade begun to receive the attention and consideration warranted by such a prevalent and debilitating condition. Within the medical community itself, women are rarely routinely screened for depression. Even while admitting the importance of the issue, the majority of obstetricians in a pilot study for the implementation of a collaborative awareness program, stated that they do not typically screen for maternal depression." (p.8) Additionally reported in the work of Palmer (2010) is that approximately 50 to 80% of new mothers "will experience a milder form of depressive symptoms most commonly referred to as postpartum or 'baby' blues. A smaller number are reported to suffer from the more serious form of PPD.' (p.9) Palmer reports "The only avenue for formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV) is as EXISTENTIAL ISSUES IN POSTPARTUM DEPRESSION an onset specifier to major depressive disorder (American Psychiatric Association (APA), 1994)." (Palmer, 2010, p. 10) It is reported by Palmer (2010) that the criteria I this DSM-IV classification is of the nature that "are so narrow that diagnosis can only be given if the onset is within the first four weeks after giving birth." (2004, p. 9-10) It is important to note that not only the mother is affected by adverse effects on a long-term basis but as well, PPD has ongoing negative impacts on the children of these mothers. Palmer (2010) reports that some of the significant issues of the children of mothers with PPD include those of: (1) attachment disorders; (2) cognitive and social developmental delays; and (3) risk factors for development of psychological disorders later in life. (p.10) Adding to the complex nature of this problem are the existing attitudes in regards to pregnancy and childbirth, which only serve to "contribute to myths perpetuating the lack of attention and thus impeding the seeking of treatment." (Palmer, 2010, p. 11) The Western culture is such that idealizes pregnancy and new motherhood in what could be perceived as an extremist view and the result is that unrealistic expectations in the Western society have resulted. Palmer (2010) reports "Even from an evolutionary and biological perspective, women are often expected to embrace motherhood and perpetuate the race as inherent responsibilities. Thus, from every angle, women are pressured to not only become mothers, but also to exhibit only joy in doing so." (p. 11)

According to Palmer (2010) an emergent danger in postpartum depression becoming better known and better accepted is "that of the self-help movement. Although a large collection of books exist that inarguably provide valuable general information and guidance through symptom relief, the exclusive utilization of such resources leads to a misperception that PPD is a simple side effect of pregnancy and childbirth that can be sufficiency addressed through simple techniques. Given its prevalence, neglect in the healthcare community, societal expectations, and identified existential givens that exist within the phenomenon...

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The work of Boyd, Le, and Somberg (2005) entitled: "Review of Screening Instruments for Postpartum Depression" reports that postpartum depression (PPD) "is a serious mental health problem" and as well, PPD is a "significant public health issues because of its negative impact on women, children, and families." (p.141) It is stated that depressed mothers "often report lower levels of maternal self-efficacy than non-depressed mothers." (Boyd, Le, and Somberg, 2005, p. 141) It is problematic that approximately fifty percent of cases of PPD are undetected although there has been a recommendation for implementation of "widespread screening for maternal depression…" (Boyd, Le, and Somberg, 2005, p. 141) Boyd, Le and Somberg reports that there is a need for the availability of psychometrically sound, brief self-report instruments…for either universal or targeted community screening purposes as well as research purposes. Although self-report instruments cannot provide a diagnosis for MDD, they can identify women who need further evaluation and=or are at high risk for developing depression (2005, p. 142) Screening for PPD can enable "preventive services…targeting high risk participants and consequently preventing the negative sequelae of PPD." (Boyd, Le and Somberg, 2005, p.143) Self-report instruments include those as follows:

(1) The Beck Depression Inventory (BDI and BDI-II) Each of these have 321 items with a 4-point Likert rating scale. The uniqueness of this scale is the ability to assess for depression severity and to monitor change over time.

(2) The Center for Epidemiological Studies Depression Scale (CED-D) -- this scale has 20 items that measure depressive symptomalogy. It is reported that while this test "…has the potential to be easily administered to screen community samples, screening with the CES-D will likely miss 40% of depressed postpartum women." (Boyd, Le and Somberg, 2005, p.146)

(3) The Edinburgh Postnatal Depression Scale (EPDS) -- This is the most widely used screening instrument for PPD. This scale measures "emotional and cognitive symptoms of PPD and purposefully excludes somatic symptoms of depression except for one item measuring sleep difficulties, which may be affected by the postpartum recovery period rather than a mood disorder." (Boyd, Le and Somberg, 2005, p.146-7)

(4) The General Health Questionnaire (GHQ) -- this instrument was originally developed to detect psychiatric morbidity among general medical outpatient populations. The items measure four subscales: depression, somatic symptoms, anxiety=insomnia, and social dysfunction." (Boyd, Le and Somberg, 2005, p. 147)

(5) The Zung Self-Rating Depression Scale (Zung SDS) -- it is reported that this instruments' "Internal consistency for the total score, the affective symptoms and insomnia factor, and the cognitive factor is good, while that of the attentional symptoms factor is moderate. Its test -- retest reliability for postpartum women is not published." (Boyd, Le and Somberg, 2005, p. 148)

The work of Phelan, Khoury, Atherton, and Khan (2007) entitled "Maternal Depression, Child Behavior and Injury" reports that mothers who have symptoms "consistent with clinical depression have been shown to be less likely to have functioning smoke detectors in their homes, to report use of child occupant restraint and electrical socket covers, and the back-to-sleep position for their infants compared with non-depressed mothers.3-4 In another study, depressive symptoms in mothers of children 2 -- 4 months of age were not associated with emergency department visits for injury 24 months later; in addition, the persistence of depressive symptoms in the mothers in this study was not associated with visits for well-child checks, acute care, or emergency department visits for care or injury in their children." ( p.403) Key findings reported in the study of Phelan, Koury, Atherton and Khan (2007) include the following stated findings:

"Depressive symptoms in mothers were associated with injury outcomes in their children… there was a 4% increase in injury risk and a 6% increase in the risk of externalizing behavior problems in the children. The recognition and treatment of depressive symptoms in mothers of young children may afford opportunities for the amelioration of behavior problems and medically attended injuries in their children." (Phelan, Koury, Atherton and Khan, 2007)

The work of Posmontier and Waite (2011) entitled "Social Energy Exchange Theory for Postpartum Depression" reports that "according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR; American Psychiatric Association, 2000), the symptoms of PPD are identical to non-postpartum major depression except for dramatic neuroendocrine changes, adjustments…